University of Texas MD Anderson Cancer Center Goes a Record 143 Days with No Patient Falls

This story originally appeared in IHI's 2007 Annual Progress Report.
When patients fall in the hospital, it does more than add insult to injury. Often it adds injury. In fact, 10 percent of fatal falls among older adults occur in the hospital. As part of its participation in the Transforming Care at the Bedside initiative, the MD Anderson Cancer Center at the University of Texas in Houston decided to focus on preventing falls.
“We looked at the characteristics of patients who fell,” says Beverly Nelson, MS, RN, CNAA, Director of Nursing Practice Programs. Data provided insights into some common situations that were leading to falls. “We discovered that many people who had had a particular kind of GI surgery were falling,” says Nelson. “Because these patients can develop diarrhea after surgery, we found that putting a bedside commode nearby reduced falls.”
They also instituted hourly safety checks on that unit, in which a nurse checks on the patients and offers assistance with toileting or any other activity that requires patients to be mobile. 
Nelson says that safety checks are now part of the institutional policy for all patients. “Falls don’t correlate as much with age as people might think,” she says. “Sometimes younger patients think they have more energy or strength than they do. That’s why we need to be vigilant about preventing falls for all patients.”
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